This case involves a fifty-year-old female patient with an unremarkable past medical history. The patient awoke one morning with difficulty speaking, left-sided face drop and left-sided weakness. She was rushed to the hospital by her husband. On admission, a CT scan was performed to investigate the possibility of a stroke. It took half an hour to receive the CT scan results. The imaging did not show any signs of hemorrhaging in the patient’s brain. The treating ER doctor evaluated the patient and requested a neurology consult which took another hour. The treating neurologist decided not to administer t-PA and instead transferred the patient to another hospital, for treatment by an interventional radiologist. It took an additional three hours to transport the patient to the next facility. The patient underwent a procedure to attempt to retrieve the clot by means of the endovascular protocol. The patient passed away from complications of the procedure.
Question(s) For Expert Witness
1. What are the proper procedures when a patient is taken to the ER with symptoms of a stroke?
2. Would the administration of t-PA have saved this woman's life or helped her recover with minimal deficits?
Expert Witness Response
Proper procedure requires that on admission the initial treating physician to establish a time of onset of the stroke. This is taken to be the time the patient was "last known to be normal". When waking up with a stroke, the time of onset is typically taken as the night before unless the patient woke up in the night and had a normal conversation with someone who could verify that (at the ER or via phone). If a patient wakes up with a deficit, then the stroke is assumed to have started when the patient went to bed - in this case likely several hours outside the window for IV t-PA and possibly outside the typical 6-hour window for intravascular intervention. Depending on the circumstances and location of the stroke (anterior vs. posterior circulation), it may not have been indicated to do an endovascular procedure. Endovascular procedures for strokes are not FDA approved, although the devices are approved to remove clots. Recent studies demonstrate no benefit to adding endovascular procedures to the acute treatment of stroke.
About the author
Dr. Faiza Jibril
Dr. Faiza Jibril has extensive clinical experience ranging from primary care in the United Kingdom, to pediatrics and child abuse prevention at Mount Sinai Hospital, to obstetrics in Cape Town, South Africa. Her post-graduate education centered on clinical research and medical ethics. Dr. Jibril is currently Head of Sales in the US and Canada for Chambers and Partners - a world leading legal ranking and insights intelligence company.
